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Some Criteria to Change for Onasemnogene Abeparvovec-xioi (Zolgensma) Effective February 1, 2023

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after February 1, 2023, Texas Medicaid will update some criteria for onasemnogene abeparvovec-xioi (Zolgensma) as follows:

  • A neurologist prescription or consultation is not required.
  • The diagnosis requirement for prior authorization requests is a confirmed diagnosis of spinal muscular atrophy (diagnosis code G120), based on gene mutation analysis with biallelic survival motor neuron 1 mutation (deletion or point mutation).

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.69.2, “Documentation Requirements,” for additional prior authorization requirements.

For more information, call the TMHP Contact Center at 800-925-9126.